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Chapter: Chapter 57: Management of Patients With Burn Injury

Multiple Choice

1. A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness Ans: D Chapter: 57 Client Needs: D-4 Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Nursing Process Objective: 2 Page and Header: 1720, Overview to Burn Injury Feedback: A full-thickness burn involves total destruction of the epidermis and dermis and, in

some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Full partial thickness is not a depth of burn. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis and the patient will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis and the patient will complain of pain and sensitivity to cold air.

2. The nursing instructor is going over burn injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care? A) Emergent B) Immediate resuscitative C) Acute D) Rehabilitation Ans: C Chapter: 57 Client Needs: D-1 Cognitive Level: Application Difficulty: Difficult Integrated Process: Nursing Process Objective: 6 Page and Header: 1729, Management of Burn Injury Feedback: The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (ie, wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting), pain management, and nutritional support are priorities at this stage and are discussed in detail in the following sections. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

3. A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what?

A) B) C) D)

Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis Hypokalemia, hyponatremia, elevated hematrocrit, and metabolic alkalosis

Ans: A Chapter: 57 Client Needs: D-4 Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Nursing Process Objective: 4 Page and Header: 1723, Overview to Burn Injury Feedback: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amount of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.

4. The patient you are caring for has an electrical burn and has developed thick eschar over the burn wound. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A) Silver sulfadiazine 1% (Silvadene) water-soluble cream B) Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C) Silver nitrate 0.5% aqueous solution D) Acticoat Ans: B Chapter: 57 Client Needs: D-2 Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Nursing Process Objective: 5 Page and Header: 1736, Management of Burn Injury Feedback: Mafenide acetate 10% hydrophilic-based cream is the agent of choice for electrical burns because of its ability to penetrate thick eschar.

5. The occupational health nurse is called to the floor of the factory where a patient has sustained a

flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to cool the burn. How will the nurse cool the burn? A) Apply ice to the site of the burn for 5 to 10 minutes. B) Wrap the patient's affected extremity in ice until help arrives. C) Apply an oil-based substance or butter to the burned area until help arrives. D) Wrap cool towels around the affected extremity intermittently. Ans: D Chapter: 57 Client Needs: D-3 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 7 Page and Header: 1726, Management of Burn Injury Feedback: Once the burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage. However, never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

6. The emergency department nurse has just admitted a patient with a burn. The nurse recognizes that the patient is likely to experience a local and systemic response to the burn when the burn exceeds a total body surface area (TBSA) of what? A) 10% B) 15% C) 20% D) 25% Ans: D Chapter: 57 Client Needs: D-4 Cognitive Level: Comprehension Difficulty: Moderate Integrated Process: Nursing Process Objective: 2 Page and Header: 1726, Management of Burn Injury Feedback: If the burn exceeds 20% to 25% TBSA, a nasogastric tube is inserted and connected to low intermittent suction. Often, patients with large burns become nauseated as a result of the gastrointestinal effects of the burn injury, such as paralytic ileus, and the effects of medication such

as opioids. All patients who are intubated should have a nasogastric tube inserted to decompress the stomach and prevent vomiting. This makes options A, B, and C incorrect.

7. The nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A) 2 days B) 3 days C) 5 days D) A week Ans: A Chapter: 57 Client Needs: D-4 Cognitive Level: Application Difficulty: Difficult Integrated Process: Nursing Process Objective: 7 Page and Header: 1726, Management of Burn Injury Feedback: Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. Changes detected by x-ray and arterial blood gases may occur as the effects of resuscitative fluid and the chemical reaction of smoke ingredients with lung tissues become apparent. Therefore options B, C, and D are incorrect.

8. A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? A) Early enteral feeding B) Administration of prophylactic antibiotics C) Bowel cleansing procedures D) Administration of stool softeners Ans: A Chapter: 57 Client Needs: D-3 Cognitive Level: Application Difficulty: Difficult

Integrated Process: Nursing Process Objective: 6 Page and Header: 1735, Management of Burn Injury Feedback: If the intestinal mucosa receives some type of protection against permeability change, infection could be avoided. Early enteral feeding is one step to help avoid this increased intestinal permeability and prevent early endotoxin translocation. Antibiotics are seldom prescribed prophylactically because of the risk of promoting resistant strains of bacteria. A bowel cleansing procedure would not be ordered for this patient. The administration of stool softeners would not assist in avoiding increased intestinal permeability and prevent early endotoxin translocation.

9. A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. What would be the nurse's priority concern about this patient? A) Fluid status B) Risk of infection C) Body image D) Level of pain Ans: A Chapter: 57 Client Needs: D-4 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 4 Page and Header: 1742, Management of Burn Injury Feedback: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection, body image, and pain are significant areas of concern, but are less urgent than fluid status.

10. The nurse is preparing the patient for mechanical debridement and informs the patient that this will involve: A) A spontaneous separation of dead tissue from the viable tissue B) Use of surgical scissors, scalpels or forceps to remove the eschar until the point of pain and bleeding occurs C) Shaving of burned skin layers until bleeding, viable tissue is revealed D) Early closure of the wound Ans: B

Chapter: 57 Client Needs: D-4 Cognitive Level: Application Difficulty: Difficult Integrated Process: Teaching/Learning Objective: 5 Page and Header: 1737, Management of Burn Injury Feedback: Mechanical debridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical debridement can also be accomplished through the use of topical enzymatic debridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural debridement. Early wound closure and shaving the burned skin layers are examples of surgical debridement.

11. A patient with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the appropriate nursing intervention when this separation occurs? A) Reinforce the Biobrane dressing with another piece of Biobrane. B) Remove the Biobrane dressing and apply a new dressing. C) Trim away the separated Biobrane. D) Notify the physician for further emergency related orders. Ans: C Chapter: 57 Client Needs: D-3 Cognitive Level: Application Difficulty: Difficult Integrated Process: Nursing Process Objective: 7 Page and Header: 1738, Management of Burn Injury Feedback: As the Biobrane gradually separates, it is trimmed, leaving a healed wound. When the Biobrane dressing adheres to the wound, the wound remains stable and the Biobrane can remain in place for 3 to 4 weeks. You would not reinforce the Biobrane, or remove it and apply a new dressing. Nor would you notify the physician for further orders.

12. An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What factors does the nurse know are considered when determining the depth of burn?

A) B) C) D)

Causative agent Visual observation of burned area Area of body burned Circumstances of the accident

Ans: A Chapter: 57 Client Needs: D-4 Cognitive Level: Analysis Difficulty: Moderate Integrated Process: Nursing Process Objective: 2 Page and Header: 1721, Overview to Burn Injury Feedback: The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. To determine the depth of the burn you do not take into consideration you visual observation of the burned area, how much of the body is burned, or the circumstances of the accident.

13. The nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A) Activity intolerance B) Anxiety C) Impaired nutrition: less than body requirements D) Acute pain Ans: D Chapter: 57 Client Needs: D-1 Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Nursing Process Objective: 6 Page and Header: 1729, Management of Burn Injury Feedback: Pain is inevitable during recovery from any burn injury. Pain in the burn patient has been described as one of the most severe causes of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid diagnoses, the presence of pain may contribute to these diagnoses and management of the patient's pain is priority as it may have a direct correlation to these nursing diagnoses.

14. The triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? A) Cover the burn with ice and secure with a towel. B) Apply butter to the area that is burned. C) Immerse the child in a cool bath. D) Avoid touching the burned area and seek medical attention. Ans: C Chapter: 57 Client Needs: D-3 Cognitive Level: Application Difficulty: Moderate Integrated Process: Teaching/Learning Objective: 3 Page and Header: 1726, Management of Burn Injury Feedback: After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure. You do not put ice on the burn, nor do you put butter on the burn. You do not need to avoid touching the burn.

15. The nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment? A) 4 to 6 hours a day for 6 months B) Daily for 2 to 3 months after the injury C) Continuously D) At night while sleeping for a year after the injury Ans: C Chapter: 57 Client Needs: D-3 Cognitive Level: Application Difficulty: Difficult Integrated Process: Teaching/Learning Objective: 5 Page and Header: 1747, Management of Burn Injury Feedback: Garments are worn continuously (ie, 23 hours a day). Therefore options A, B and D are incorrect.

16. A patient is brought to the ED by paramedics who report the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is a priority in the care of a patient who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management Ans: D Chapter: 57 Client Needs: D-3 Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Nursing Process Objective: 6 Page and Header: 1726, Management of Burn Injury Feedback: Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early postburn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.

17. A patient arrives in the emergency department after being burned in a house fire. The patient's burns cover the face and the left forearm. What percentage of burn does the patient have? A) 10% B) 25% C) 9% D) 18% Ans: D Chapter: 57 Client Needs: D-4 Cognitive Level: Analysis Difficulty: Moderate Integrated Process: Nursing Process Objective: 1 Page and Header: 1721, Overview to Burn Injury Feedback: When estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 9%, and the forearm is 9% for a total of 18% in this patient.

This makes options A, B, and C incorrect.

18. The nursing instructor is teaching about the emergent/resuscitative phase of burn injury. During this phase, what would the nursing instructor tell the students they should closely monitor in the laboratory values? A) Sodium deficit B) Bleeding time C) Potassium deficit D) Decreased hematocrit Ans: A Chapter: 57 Client Needs: D-1 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 4 Page and Header: 1723, Overview to Burn Injury Feedback: Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include potassium excess, sodium deficit, base-bicarbonate deficit, and elevated hematocrit. This makes options B, C, and D incorrect.

19. The nursing students are doing clinical hours on the burn unit. A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. A nursing student asks why this goal is important when the patient is fighting for his life. What should the burn nurse respond? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent heterotopic ossification Ans: C Chapter: 57 Client Needs: D-3 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 6 Page and Header: 1745, Management of Burn Injury

Feedback: To prevent the complication of contractures the nurse will establish a goal to maintain position of joints in alignment. Gentle range of motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures. This makes options A, B, and D incorrect.

20. Grafts taken from one body and grafted onto another body are called what? A) Allograft B) Homograft C) Heterograft D) Autograft Ans: B Chapter: 57 Client Needs: D-4 Cognitive Level: Knowledge Difficulty: Easy Integrated Process: Nursing Process Objective: 5 Page and Header: 1738, Management of Burn Injury Feedback: Homografts are grafts derived from one person's body and used on another part of a different person's body.

21. A nurse taking care of a burn patient is asked why the patient is losing so much weight. What would be the nurse's most appropriate answer? A) Your body has built up extra fat deposits even though you haven't been eating very much. B) Your body has used your fat deposits for fuel because you haven't been eating very much. C) Your reserve fat deposits have been catabolized because you have been eating so much. D) You have lost fluids and you haven't eaten very much. Ans: B Chapter: 57 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Process: Communication and Documentation Objective: 7 Page and Header: 1742, Management of Burn Injury

Feedback: Patients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized, fluids are lost, and caloric intake may be limited. Options A, C, and D are incorrect because they give the patient misinformation.

22. Where do most burn injuries occur? A) On the road B) At home C) At work D) Recreational accidents Ans: B Chapter: 57 Client Needs: B Cognitive Level: Knowledge Difficulty: Moderate Integrated Process: Teaching/Learning Objective: 1 Page and Header: 1719, Overview to Burn Injury Feedback: Of those people admitted to burn centers, 47% are injured at home, 27% on the road, 8% are occupational, 5% are recreational, and the remaining 13% are from other sources. Therefore options A, C, and D are incorrect.

Multiple Selection

23. A 45-year-old man is brought in by Life-Flight after a motor vehicle accident is which he was trapped in a burning vehicle. The burn team is estimating the patient's likelihood of survival based on the severity of the burn injury. The emergency department nurse knows that the severity of the injury is based on what factors? (Mark all that apply.) A) Age B) Depth of the burn C) Presence of inhalation injury D) Family support E) Psychological state of the patient Ans: A, B, C Chapter: 57

Client Needs: D-4 Cognitive Level: Analysis Difficulty: Moderate Integrated Process: Nursing Process Objective: 2 Page and Header: 1720, Overview to Burn Injury Feedback: The severity of each burn injury is determined by multiple factors that when assessed help the burn team estimate the likelihood that a patient will survive and plan the care for each patient. These factors include age of the patient; depth of the burn; amount of surface area of the body that is burned; presence of inhalation injury; presence of other injuries; location of the injury in special care areas such as the face, perineum, hands, and feet; and presence of a past medical history. Options D and E are not factors that bear on the severity of the injury.

Multiple Choice

24. You have just reported to the burn unit to start your shift. Four new patients have been admitted in the past 12 hours. Which patient is most likely to have life-threatening complications? A) A 4-year-old scald victim burned over 24% of the body B) A 27-year-old healthy male burned over 36% of his body in a car accident C) A 39-year-old female with myasthenia gravis burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire Ans: A Chapter: 57 Client Needs: D-3 Cognitive Level: Comprehension Difficulty: Easy Integrated Process: Nursing Process Objective: 2 Page and Header: 1720, Overview to Burn Injury Feedback: Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the patient.

25. A burn patient is brought to the emergency department. The nurse knows that the first

systemic event after a major burn injury is what? A) Hemodynamic instability B) Metabolic acidosis C) Hypovolemia D) Hyperkalcemia Ans: A Chapter: 57 Client Needs: D-4 Cognitive Level: Application Difficulty: Difficult Integrated Process: Nursing Process Objective: 3 Page and Header: 1722, Overview to Burn Injury Feedback: The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. Options B, C, and D occur, they are just not the first event to happen.

26. A burn victim is admitted to the Intensive Care Unit to stabilize and begin fluid resuscitation before transport to the burn center. If inadequate fluid resuscitation occurs what happens to the patient? A) Becomes unresponsive B) Distributive shock C) Death D) Hypovolemic shock Ans: B Chapter: 57 Client Needs: D-4 Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Nursing Process Objective: 3 Page and Header: 1723, Overview to Burn Injury Feedback: Prompt fluid resuscitation maintains the blood pressure in the low-normal range and improves cardiac output. Despite adequate fluid resuscitation, cardiac filling pressures (central venous pressure, pulmonary artery pressure, and pulmonary artery wedge pressure) remain low during the burn-shock period. If inadequate fluid resuscitation occurs, distributive shock occurs

27. An emergency department nurse has just received a burn victim brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. The nurse knows that pathophysiologic changes resulting from major burns during the initial burn-shock period include what? A) Hyper-dynamic anabolism B) Hyper-metabolic catabolism C) Decreased cardiac output D) Organ hyper-function Ans: C Chapter: 57 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 3 Page and Header: 1721, Overview to Burn Injury Feedback: Pathophysiologic changes resulting from major burns during the initial burn-shock period include tissue hypo-perfusion and organ hypo-function secondary to decreased cardiac output, followed by a hyper-dynamic and hyper-metabolic phase. Options A and B are distracters for this question.

28. A male patient, 16 years old, comes to the emergency department (ED) after burning his right hand and arm while working on a friend's car. The injury is determined to be a superficial burn and it is treated. What would the nurse teach the patient before discharging him home to return on a daily basis for dressing changes? A) As your arm swells, push on your fingernails. If it takes longer than 5 seconds for them to get pink come back to the ED. B) You should be fine until you come back tomorrow for your dressing change. C) Drink lots of fluids and elevate the arm. D) The burned area will start to swell in about 4 hours and blisters will form. If you think the dressing is too tight come back to the ED. Ans: D Chapter: 57 Client Needs: D-3 Cognitive Level: Application Difficulty: Difficult Integrated Process: Caring Objective: 3

Page and Header: 1723, Overview to Burn Injury Feedback: In a superficial burn there is loss of capillary integrity and fluid is localized to the burn itself, resulting in blister formation and edema only in the area of injury. Capillary refill should be 3 seconds or less. Options B and C are distracters for this question.

29. A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and both legs. The burns to the lower legs are circumferential. The nurse knows to monitor closely for what as the edema in this patient increases? A) Ischemia B) Eschar C) Hyper-profusion to the burned area D) Increased fluid loss through the burned area Ans: A Chapter: 57 Client Needs: D-3 Cognitive Level: Comprehension Difficulty: Moderate Integrated Process: Nursing Process Objective: 3 Page and Header: 1723, Overview to Burn Injury Feedback: As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. The physician may need to perform an escharotomy, a surgical incision into the eschar (devitalized tissue resulting from a burn), to relieve the constricting effect of the burned tissue.

30. A nurse on the burn unit is caring for a patient who has gone into the acute phase of her burn. What would be important for the nurse to monitor the patient for? A) Hypometabolism B) Hyponatremia C) Hyperkalemia D) Hypoglycemia Ans: B Chapter: 57 Client Needs: D-3

Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Caring Objective: 4 Page and Header: 1723, Overview to Burn Injury Feedback: Hyponatremia is common during the first week of the acute phase, as water shifts from the interstitial space to the vascular space. Hypermetabolism can occur up to 1 year after the burn. Hyperkalemia occurs in the emergent phase of the burn. In a burn patient there is a hyperglycemic response, not a hypoglycemic response.

31. The acute phase of the burn begins 48 to 72 hours after the burn. What begins at this time? A) Cardiac output decreases B) Renal failure begins C) Diuresis D) Fluid moves from intravascular compartment to interstitial spaces Ans: C Chapter: 57 Client Needs: D-3 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 4 Page and Header: 1729, Management of Burn Injury Feedback: As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. Cardiac output should increase and renal output should increase.

Multiple Selection

32. As the patient begins the acute phase of a burn, cautious administration of fluids and electrolytes continues. The nurse knows that this caution is because of what? (Mark all that apply.) A) Patient is considered in critical condition B) Cardiac function is decreased C) Patient's physiologic responses to the burn injury

D) Losses of fluid from large burn wounds E) Shifts in fluid from the interstitial to the intravascular compartment Ans: C, D, E Chapter: 57 Client Needs: D-3 Cognitive Level: Application Difficulty: Difficult Integrated Process: Nursing Process Objective: 4 Page and Header: 1730, Management of Burn Injury Feedback: Cautious administration of fluids and electrolytes continues during this phase of burn care because of the shifts in fluid from the interstitial to the intravascular compartment, losses of fluid from large burn wounds, and the patient's physiologic responses to the burn injury.

Multiple Choice

33. What is the nursing goal during the acute phase of a burn? A) To ultimately prevent or control infection in the burn population B) To prevent hypervolemia in the burn population C) To manage pain in a proactive way for the patient's comfort D) To provide emotional support as the changes in body image become internalized in the patient Ans: A Chapter: 57 Client Needs: D-3 Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Nursing Process Objective: 5 Page and Header: 1734, Management of Burn Injury Feedback: The nursing goal is to provide protection and safety in the patients' environment to ultimately prevent or control infection in the burn population. This makes options B, C, and D incorrect.

34. A nurse is caring for a patient during the acute phase of the burn. The nurse knows he is

responsible for what? A) Restricting visitors to prevent infection B) Closely scrutinizing the burn wound to detect early signs of infection C) Cleaning the patient's room D) Maintaining the patient in a sterile environment Ans: B Chapter: 57 Client Needs: D-3 Cognitive Level: Analysis Difficulty: Moderate Integrated Process: Nursing Process Objective: 5 Page and Header: 1735, Management of Burn Injury Feedback: The nurse is responsible for providing a clean and safe environment and for closely scrutinizing the burn wound to detect early signs of infection. Visitors are not restricted to a burn patient. The nurse does not clean the patient's room. The patient is maintained in a clean environment, not a sterile environment.

35. It is time to change the dressings on a burn patient. What does the nurse do to reduce pain and discomfort at this time? A) The nurse lets the patient decide on when to change the dressing. B) The nurse skip's the dressing change if the patient is really uncomfortable. C) The nurse changes dressings as quickly as possible. D) The nurse lets the aide do the painful part of the dressing change. Ans: C Chapter: 57 Client Needs: D-3 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 5 Page and Header: 1743, Management of Burn Injury Feedback: The nurse works quickly to complete treatments and dressing changes to reduce pain and discomfort. Letting the patient decide the time of the dressing change lets the patient feel more in control. It doesn't reduce pain and discomfort. The nurse should never skip an ordered dressing change. You never delegate a dressing change on a burn patient.

36. You are caring for a burn patient who is in the later stages of the acute phase of the burn injury. What is an important factor in your care of the patient? A) Immobilizing the patient B) Maintaining splints and functional devices C) Maintaining ongoing discussion about the patient with a psychologist D) Prevention of DVT Ans: D Chapter: 57 Client Needs: D-3 Cognitive Level: Application Difficulty: Moderate Integrated Process: Caring Objective: 6 Page and Header: 1743, Management of Burn Injury Feedback: Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the patient is important. The nurse monitors the splints and functional devices, but does not maintain them. The nurse does not maintain discussion with a psychologist about the patient.

Multiple Selection

37. Your patient is in the acute phase of a burn injury. One of the nursing diagnoses on the plan of care is ineffective coping due to burn injury and altered body image. What interventions can you institute to help this patient cope more effectively? (Mark all that apply.) A) Promote truthful communication B) Allowing the patient to set specific expectations C) Assist the patient in practicing appropriate strategies D) Stop the patient's manipulation of staff E) Give positive reinforcement when appropriate Ans: A, C, E Chapter: 57 Client Needs: C Cognitive Level: Application Difficulty: Difficult Integrated Process: Caring Objective: 6

Page and Header: 1744, Management of Burn Injury Feedback: The nurse can assist the patient to develop effective coping strategies by setting specific expectations for behavior, promoting truthful communication to build trust, helping the patient practice appropriate strategies, and giving positive reinforcement when appropriate. The nurse should set specific expectations, not the patient. Each staff member needs to stop the manipulation of the patient with the involved staff member.

Multiple Choice

38. What is a priority in the rehabilitation phase of the burn injury? A) Monitoring fluid and electrolyte imbalances B) Patient and family education C) Assessing wound healing D) Documenting family support Ans: B Chapter: 57 Client Needs: D-4 Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Caring Objective: 6 Page and Header: 1744, Management of Burn Injury Feedback: Patient and family education is a priority in the acute and rehabilitation phases. There should be no fluid and electrolyte imbalances in the rehabilitation phase. Assessing wound healing is an ongoing function but it is not a priority in the rehabilitation phase. Documenting family support is not a priority in the rehabilitation phase.

39. A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse I can't wait to have surgery to reconstruct my face so I look normal again. What would be the nurse's best response? A) You know, nothing can be done until your scars mature. It is something the doctor will talk to you about in the first few years after discharge. B) That is something for you to talk to your doctor about. C) I know this is really important to you, but you have to realize that no one can make you look like you used to.

D) You will have most of these scars for the rest of your life. Ans: A Chapter: 57 Client Needs: D-4 Cognitive Level: Analysis Difficulty: Moderate Integrated Process: Nursing Process Objective: 7 Page and Header: 1747, Management of Burn Injury Feedback: Burn reconstruction is a treatment option after all scars have matured and is discussed within the first few years after injury. Options B and C are true statements but not the best statements. The nurse does not know for sure how much reconstruction can be done.

Multiple Selection

40. A patient in the rehabilitation phase of the burn injury is setting goals with the nurse. What goals would be appropriate at this time? (Mark all that apply.) A) Increased participation in activities of daily living B) Increased understanding of the planned follow-up care C) Increased control of treatment D) Adjustment to alterations in lifestyle E) Recognition of complications Ans: A, B, D Chapter: 57 Client Needs: D-4 Cognitive Level: Application Difficulty: Difficult Integrated Process: Nursing Process Objective: 7 Page and Header: 1748, Management of Burn Injury Feedback: The major goals for the patient include increased participation in activities of daily living; increased understanding of the injury, treatment, and planned follow-up care; adaptation and adjustment to alterations in body image, self-concept, and lifestyle; and absence of complications.